Diet modification for dysphagia

Diet modifications for dysphagia are suggested dietary changes, particularly regarding food consistencies, directed at improving a patient’s ability to swallow and at avoiding aspiration. For example, an individual who is struggling with aspiration might be advised to avoid thin liquids and use thicker or carbonated liquids instead. Or this individual might be advised to avoid composite foods, since his or her swallowing deficiency could make it harder to “stay organized” with several consistencies in the mouth at once.

Swallowing therapy

Swallowing therapy is typically provided by a speech-language pathologist (and, more informally and adjunctively, by other healthcare professionals). General areas of teaching might include: choosing wisely which food types and consistencies to eat; swallowing maneuvers such as tucking the chin, double swallow, effortful swallow, head turning, and supraglottic swallow; and direct exercises for the tongue, pharynx, palate, and larynx.

Relative voice rest

A reduction in a person’s amount and manner of voice use. When we suggest relative voice rest for patients, we sometimes tell them to think of using “vocal prudence,” or to use their voice only for the “business of life,” but not for pleasure-talking or purely social interaction. Some use a concept such as “you can talk for five minutes out of every 30.” Still others use the 7-point talkativeness scale and ask a person to be a “1” or a “2,” where 1 is “Clint Eastwood” and 7 is a life-of-the-party, highly sociable person.

Laryngeal closure or diversion for aspiration

One of several potential treatments for a person who suffers from gross aspiration to the extent that, even without taking any nourishment by mouth, this person has repeatedly incurred aspiration pneumonia (i.e., due to saliva alone). In this scenario, subsequent pneumonias start to become more severe and even life-threatening as the lungs progressively deteriorate. At this point, there is a list of options:

  1. Tracheotomy. This procedure makes it possible to suction out the trachea and any aspirated secretions on a frequent basis, and to inflate a balloon on the outside of the tube in order to reduce the volume of aspirated secretions.
  2. Tracheal transection, with or without diversion. This option deprives the person of voice and makes him or her an obligate neck breather. In this procedure, a physician transects the trachea and sews the stump below the larynx completely shut. The lower stump is sewn to the skin, making the person a neck breather. If the person’s ability to swallow returns, then theoretically the trachea can be reattached. A variant of this procedure is to sew the upper stump into the esophagus so that secretions that enter the larynx can drain into the esophagus.
  3. Total laryngectomy. This option is the most definitive way to stop life-threatening aspiration. Its best application is in an individual whose ability to swallow is certain not to recover. Total laryngectomy consigns the person to neck breathing (like option 2), but a tracheoesophageal voice can be established and swallowing becomes perfectly safe, because the airway and foodway are completely separated.

Supraglottic swallow

A swallowing technique in which a person coughs right at the end of a swallow to help prevent any swallowed food or liquid from going down into the airway. This technique is especially useful for individuals who have undergone a supraglottic laryngectomy, because the upper part of the larynx (epiglottis, aryepiglottic cords, false cords, etc.) has been removed and can no longer help to shield or divert swallowed material.

For each and every swallow, the person will do as follows: first, finish chewing; then, hold the food or liquid in the mouth and fill the lungs with air; then, with the food or liquid still in the mouth, hold his or breath; then, swallow forcefully and, without hesitation, cough immediately on the tail end of the swallow. At our practice we call this technique a “swallowcough,” to signify that the cough occurs using pent-up air from the lungs, and not air drawn in between the swallow and the cough.

Effortful swallow technique

To perform the action of swallowing with greater conscious effort and vigor than comes naturally or seems necessary to the person. Normally, a person swallows without much conscious effort. However, individuals who suffer from weaker or less organized swallowing function (e.g., presbyphagia) can benefit from a superimposition of volitional effort. Just before swallowing any food or liquid, the person is told by the swallowing therapist, a family member, or him or herself: “Now, swallow hard!”

Chin tuck maneuver

A maneuver in which, just before swallowing, a person drops the chin to or toward the chest. This maneuver has the effect of narrowing the pharynx so that the propulsive forces of swallowing have a smaller passageway in which to work, which can help to counteract some individuals’ tendency toward hypopharyngeal pooling, laryngeal penetration, or even aspiration. The chin tuck maneuver can be “tested” for its efficacy during both the videoendoscopic swallowing study and videofluoroscopic swallowing study, in order to determine whether this maneuver should become a formal part of the patient’s swallowing strategy.

Neck dissection

Neck dissection is a surgical procedure that removes lymph node-bearing tissue in the neck, either because it contains known metastases or is at high risk of containing yet-undetected (i.e., microscopic) metastases. Neck dissection is often combined with removal of the primary tumor. The original neck dissection, today called a radical neck dissection, removes fat and lymph nodes, the jugular vein, and sternocleidomastoid muscle. Later types of neck dissections were devised to reduce the morbidity of this surgery without compromising effectiveness. The commonest variants today are called selective neck dissections; these remove removes fat and lymph nodes from targeted parts of the neck most likely to be involved with metastasis, and tend to spare muscles of the neck, the jugular vein, and cranial nerve 11.